Art by Caitlin Roark
Modeled by Katie Nance
“It cuts across all segments of society,” said Professor Barry Lester, director of the Brown Center for the Study of Children at Risk and professor of psychiatry and human behavior and pediatrics at Brown University.
Prenatal substance use affects women of all regions, races and socioeconomic groups, Dr. Hendree Jones, executive director of University of North Carolina (UNC) Horizons Program and professor in the UNC Department of Obstetrics and Gynecology, reiterated.
While women who are not pregnant and all men need only to consider the effects that substances have on their bodies, expectant mothers have another consideration with every decision they make: How will this affect the baby?
“It is absolutely critical not to drink any alcohol during pregnancy because there is no safe amount,” said Dr. Margaret Lynn Yonekura, OB-GYN and associate professor of clinical OB-GYN at both USC and UCLA Schools of Medicine.
While the rule of “no alcohol” during pregnancy may seem obvious, Yonekura said college-educated women, particularly Caucasians, are less likely to put aside drinking during their pregnancies. She said this could be due to these women having children later in life, after graduating and starting careers, and picking up heavier drinking habits from the men they are working alongside.
This alcohol transmits through the placenta to the fetus, who cannot metabolize the alcohol at the same rate as the mother, Yonekura explained. This prenatal alcohol consumption can lead to fetal alcohol syndrome, which causes neurodevelopment issues impacting the child’s intelligence. It can also affect the development of facial features, such as upper lips and ears, reflecting the alcohol-impacted brain inside.
Fetal alcohol syndrome is a spectrum, Yonekura said. Some children may only show some signs, whereas others may be more heavily affected by their mothers’ alcohol consumption.
Yonekura said one of the most tragic cases of fetal alcohol syndrome that she witnessed was the child of two Harvard alumni and White House attorneys.
“I delivered a baby who, I could tell at birth, had fetal alcohol syndrome,” Yonekura said. “That’s how bad it was. I said, ‘Did you drink any alcohol during pregnancy?’ and she said, ‘Well, yeah, you know, I’m a professional woman.’ In order to be successful, she felt that she had to drink with the boys. And she did. She drank at lunchtime, she drank before dinner, she drank during dinner.”
Jones said alcohol is one of the substances that, when used during pregnancy, can have some of the harshest effects on a baby.
Unfortunately, Jones said there are no medications available to treat alcohol addiction during a women’s pregnancy. Naltrexone, a medicine used with non-pregnant patients, still has not been approved for prenatal use.
“Fetal alcohol syndrome is 100 percent preventable,” Yonekura said. “It’s the most common cause of mental retardation that is preventable.”
Nicotine and Tobacco
Jones said another substance proven to have highly detrimental effects on fetuses is nicotine or tobacco consumed through smoking cigarettes or vaping.
Mothers who smoke during pregnancy can have children with birth defects ranging from cleft lips to their gastrointestinal organs developing outside of their body, Yonekura said.
Other effects include a higher chance of the baby being born prematurely or having a lower birth weight, Jones said.
“Most women don’t think of smoking as causing birth defects,” Yonekura said. “They think it’s a lifestyle choice.”
There is no way to tell the extent of the damage smoking will have on a fetus, Jones said.
“You can’t just say, ‘Mom smoked 20 cigarettes a day, and therefore we are going to get outcome X,’” Jones said. “It’s incredibly complex, and it really is so individualized.”
Smoking during pregnancy can also be an indication of greater substance use, Yonekura said.
“Any person who smokes during pregnancy should be really questioned carefully because especially in California, so few women smoke,” Yonekura said. “With persistent smoking during pregnancy, you’ve got to ask them about polysubstance abuse, especially alcohol. Eighty percent of alcoholics smoke and 30 percent of smokers are alcoholics.”
Certain medications can also have adverse effects on developing babies. These medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) like Prozac or Zoloft, Lester said.
“It’s a huge issue as to what a mom does when she gets pregnant and she’s on an SSRI because on the one hand, she’s worried about the potential impact [on the baby],” Lester said. “On the other hand, if she’s off the SSRI, she’s going to get depressed — being depressed results in hormonal changes that can also affect the fetus. So you’re kind of damned if you do, damned if you don’t.”
Jones said an important thought to consider in these situations is absolute risk versus relative risk. For example, a medication may advertise that it can cause a four-fold increased risk of heart defects in babies. However, that statistic may mean it only causes the defect in one infant out of 100,000.
“Sometimes, it might be we know that there’s a risk of this medication, but we know that it’s also a predictable risk,” Jones said. “We’d rather have mom be pain-free and be comfortable and be functional. That’s going to be greater benefit long-term to mom and baby.”
“You want to be the best mom that you can and taking care of yourself, I think, is an important part of that,” Lester said.
Marijuana can harm an infant’s neurodevelopment when used during pregnancy, Yonekura said. The drug influences the connections formed between synapses in an infant’s brain.
Yonekura said researchers are finding that now, more women are using higher doses of marijuana, more frequently, during pregnancy.
“I’ve had patients say, ‘Well, it’s natural,’” Yonekura said. “And I said, ‘What do you mean it’s natural?’ ‘Well, it grows in the ground.’ OK. It’s natural, but it doesn’t mean it’s safe.”
The THC content of marijuana, the active ingredient in the drug, was around two percent in the 1970s, Yonekura said. With plant hybridization, most marijuana used now in the U.S. has THC percentages of over 25 percent with minimal CBD — another compound in marijuana that provides alleviation without a high — present to counteract the effects of THC.
“In Holland, they consider a policy of over 15 percent [THC] as a hard drug, and they don’t allow it,” Yonekura said. “It is not legal in Holland. [Marijuana] on our streets is over 25 percent. So we’ve got hard drugs on the street.”
This means that when women are consuming marijuana during pregnancy, they are using a highly potent form of the drug, whether they realize it or not.
“A lot of people think, ‘Well, it’s legal. I can use it,’” Yonekura said. “Well, yes, you can use it. It is legal, but doesn’t mean it’s safe during pregnancy. Alcohol is legal — doesn’t mean it’s safe during pregnancy. Cigarettes are legal — doesn’t mean it’s safe to smoke indiscriminately during pregnancy.”
About every 15 minutes, a baby is born with neonatal abstinence syndrome (NAS), or born dependent on opioids, according to the National Institute on Drug Abuse.
When a woman takes opioids while pregnant, the drug can transmit through the placenta, making the baby dependent on the drug as well, according to the March of Dimes. If a mother stops using opioids mid-pregnancy, she risks miscarriage or other harm befalling her infant. Babies born from opioid-using mothers can experience NAS, a withdrawal reaction to narcotic drug exposure with symptoms including low birth weight and shaking.
Doctors can prescribe pregnant mothers methadone or buprenorphine, opioids that satisfy the mother and baby’s need for an opiate without the effects of feeling high, according to The National Alliance of Advocates for Buprenorphine Treatment.
“If a mom has been using opiates illicitly like heroin, Vicodin, Oxycontin — something like that — the safest thing for her to do is to come into treatment and receive medication-assisted treatment,” Jones said.
Jones said pregnant women dealing with an opioid addiction should also receive behavioral support, which, as she has seen, has doubled quit rates.
If a baby experiences withdrawal after birth, one of the best things medical providers can do is keep the baby close to his or her mother, Jones said. Skin-to-skin contact and breastfeeding — if the mother’s HIV-negative — results in calmer babies.
“Because [the babies are] getting the drug through the breast milk, their symptoms will be a lot less,” Yonekura said. “Some may need some additional medication, but they’re not gonna be as bad as [they would] if you took them to the nursery away from the mother and let them go through withdrawal, in which case they’re just miserable, and it’s hard to watch them.”
Lester and Jones emphasized that babies born with NAS are not addicted to opioids, but are physically dependent on them.
“There’s a very important distinction between physiological dependency and addiction,” Lester said. “Addiction is a psychological phenomenon. It’s not physiological. It’s strictly psychological.”
Many individuals and articles, like the Oct. 9, 2017 article by NBC, titled “Born Addicted: the Number of Opioid-Addicted Babies is Soaring,” mistakenly refer to these infants as “born addicted.”
“When people talk about babies being born addicted, that’s completely wrong because the baby can’t be addicted because it’s psychological,” Lester said. “They can be physiologically dependent. The only drug that really causes physiological dependency are the opioids.”
Laws Surrounding Prenatal Drug Exposure
Each state handles cases of prenatal drug use differently. Tennessee is the only state that considers drug use while pregnant as child abuse, according to the American Pregnancy Association.
Others, like Rhode Island, have developed a family treatment drug court to handle these cases, Lester said.
“We develop a treatment plan for the mom, hand it to the judge and the judge gives a sentence,” Lester said. “Essentially it’s treatment. If you could follow treatments and you’d have your kid, you keep your kid unless you violate your treatments. If you don’t have your kid and you complete the treatment, then you work toward reunification and you get your kid back.”
Many women are afraid of getting the necessary help they need because they do not trust the healthcare system to help them or allow them to keep their babies, Lester said.
“They stay away from the healthcare system, which is the last thing in the world you want,” Lester said. “Developing a trusting, nonjudgmental relationship with this population is what’s absolutely critical.”
Facing the Stigma of Substance Use
In addition to the battle these pregnant women face against their addictions, these mothers-to-be — particularly those addicted to opioids — face another battle against the public’s judgmental eye.
Lester said this problem has been around since the cocaine “epidemic” of the 1980s. Society looked down on mothers using cocaine during pregnancy, seeing it as a selfish act rather than one motivated by the disease of addiction.
“[Members of society] were so desperate to prove that these kids [were] going to be damaged, and they were so anxious to go after the moms,” Lester said.
However, Lester said a study he was a part of proved cocaine had minimal effects on the babies and began to alter the public’s opinion.
Jones said pregnant women managing substance addiction face stigmas from others, as well as self-imposed judgments.
“It’s beyond stigma,” Jones said. “It’s a stigma, plus discrimination, plus prejudice that our women feel.”
This stigma is particularly harsh for these pregnant women, Jones said.
“If you’re a male, you’re looked down upon, but you’re often given an excuse — ‘Oh well, this is boys being boys,’” Jones said. “Whereas if you’re a female, then there’s sort of a double stigma. I think for our women who then become pregnant, it’s a triple threat to stigma and discrimination and prejudice. Women face discrimination in all sectors – from their family, from their friends, from their significant others, from the healthcare system, from the legal system.”
Jones emphasized this stigma is why getting help is so important for those with drug addictions, especially women who are pregnant.
“There really isn’t a place that’s a safe harbor, other than places that provide trauma-informed care and that understand substance use disorders are an illness, and it’s an illness for which we have good treatments and that recovery can happen,” Jones said. “Women, when they’re given tools to thrive to their best potential, can have amazing recoveries and can do really, really well.”
Lester said with the increase in prescription pain medication addictions, more women of higher social classes are managing opioid addictions.
“Part of the reason that this issue has become such a hot button is because all of a sudden, it’s a middle-class issue,” Lester said. “It’s not just the poor people we’re talking about, it’s now a middle-class issue, or as we like to say, it’s become ‘gentrified.’”
Jones also mentioned this expansive nature of substance addiction.
“Substance use disorders know no bounds of race, ethnicity, geography [or] socioeconomic status,” Jones said. “In some ways, it’s often women that have the most means and women that have the fewest means that tend to suffer the most because it’s incredibly isolating and sometimes hard to find services if you’re on the two extremes of our socioeconomic status.”
This can be problematic because these upper-class women may not receive the help they need in dealing with their addictions, Jones said.
“Women who are of lower socioeconomic status tend to be more quickly identified or identified at all for having a substance use disorder,” Jones said. “A lot of times I’ll hear of women that come in for labor and delivery postpartum [and] they’re not even tested for substances because they’re ‘private pay patients.’ So we actually miss opportunities to be able to intervene and provide care and support to that mother [and] child.”
Environment’s Impact on Babies
While it may be easy to assume an infant’s prenatal exposure to drugs determines their future learning abilities or the probability of their own drug use, their environment often plays a larger role, Jones said.
“It would be very simple and easy for people to say, ‘Prenatal drug exposure equals a baby [who’s] going to become an initiate of substance use themselves,’” Jones said. “But I think we need to be much more thoughtful and understand what is really happening in the home, because I think that if we look more carefully at those factors, we’re going to find factors that do a better job of explaining the variance and not just the substance exposure prenatally itself.”
“Whether or not those problems develop later on has a tremendous amount to do with the postnatal caregiving environment,” Lester said. “So if you put a fragile baby in an environment of stress, adversity, poverty [and] inadequate parenting, where the postnatal environment is really detrimental, it’s really the combination of the drug and the environment that does the kid in.”
Prenatal drug exposure does not determine a child’s future development, Lester said.
“If you put that same kid in a good environment, then there’s every reason to believe that the kid’s going to develop normally,” Lester said.
Yonekura emphasized that pregnant women managing substance addictions have often dealt with hardships such as sexual abuse. Their drug use functions as a form of self-medication against flashbacks and nightmares.
“It’s important not to condemn these women because the vast majority of them in my experience have had terrible trauma in their lives,” Yonekura said. “Most of these women are real survivors.”
Follow Madeleine Carr on Twitter: @madeleinecarr23